Measurement of single-kidney glomerular filtration function from magnetic resonance perfusion renography

Evolving Medical Imaging Techniques for the Assessment of Delayed Graft Function: A Narrative Review

Purpose of review

Delayed graft function (DGF) is a significant complication that contributes to poorer graft function and shortened graft survival. In this review, we sought to evaluate the current and emerging role of medical imaging modalities in the assessment of DGF and how it may guide clinical management.

Sources of information

PubMed, Google Scholar, and ClinicalTrial.gov up until February 2021.

Methods

This narrative review first examined the pathophysiology of DGF and current clinical management. We then summarized relevant studies that utilized medical imaging to assess posttransplant renal complications, namely, DGF. We focused our attention on noninvasive, evolving imaging modalities with the greatest potential for clinical translation, including contrast-enhanced ultrasound (CEUS) and multiparametric magnetic resonance imaging (MRI).

Key findings

A kidney biopsy in the setting of DGF can be used to assess the degree of ischemic renal injury and to rule out acute rejection. Biopsies are accompanied by complications and may be limited by sampling bias. Early studies on CEUS and MRI have shown their potential to distinguish between the 2 most common causes of DGF (acute tubular necrosis and acute rejection), but they have generally included only small numbers of patients and have not kept pace with more recent technical advances of these imaging modalities. There remains unharnessed potential with CEUS and MRI, and more robust clinical studies are needed to better evaluate their role in the current era.

Limitations

The adaptation of emerging approaches for imaging DGF will depend on additional clinical trials to study the feasibility and diagnostic test characteristics of a given modality. This is limited by access to devices, technical competence, and the need for interdisciplinary collaborations to ensure that such studies are well designed to appropriately inform clinical decision-making.

Basic principles and new advances in kidney imaging

Over the past few years, clinical renal imaging has seen great advances, allowing assessments of kidney structure and morphology, perfusion, function and metabolism, and oxygenation, as well as microstructure and the interstitium. Medical imaging is becoming increasingly important in the evaluation of kidney physiology and pathophysiology, showing promise in management of patients with renal disease, in particular with regard to diagnosis, classification, and prediction of disease development and progression, monitoring response to therapy, detection of drug toxicity, and patient selection for clinical trials. A variety of imaging modalities, ranging from routine to advanced tools, are currently available to probe the kidney both spatially and temporally, particularly ultrasonography, computed tomography, positron emission tomography, renal scintigraphy, and multiparametric magnetic resonance imaging. Given that the range is broad and varied, kidney imaging techniques should be chosen based on the clinical question and the specific underlying pathologic mechanism, taking into account contraindications and possible adverse effects. Integration of various modalities providing complementary information will likely provide the greatest insight into renal pathophysiology. This review aims to highlight major recent advances in key tools that are currently available or potentially relevant for clinical kidney imaging, with a focus on non-oncological applications. The review also outlines the context of use, limitations, and advantages of various techniques, and highlights gaps to be filled with future development and clinical adoption.

SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance

The Society for Cardiovascular Magnetic Resonance (SCMR) last published its comprehensive expert panel report of clinical indications for CMR in 2004. This new Consensus Panel report brings those indications up to date for 2020 and includes the very substantial increase in scanning techniques, clinical applicability and adoption of CMR worldwide. We have used a nearly identical grading system for indications as in 2004 to ensure comparability with the previous report but have added the presence of randomized controlled trials as evidence for level 1 indications. In addition to the text, tables of the consensus indication levels are included for rapid assimilation and illustrative figures of some key techniques are provided.

The Accuracy of Renal Function Measurements in Obstructive Hydronephrosis Using Dynamic Contrast-Enhanced MR Renography

OBJECTIVE. The objective of our study was to assess the accuracy of glomerular filtration rate (GFR) evaluation in patients with obstructive hydronephrosis using dynamic contrast-enhanced MR renography (DCE-MRR). MATERIALS AND METHODS. A group of 28 adult volunteers were enrolled in this study: 13 without hydronephrosis, eight with low-grade hydronephrosis, and seven with high-grade hydronephrosis. The GFR obtained from DCE-MRR (GFR_MRR) and the GFR obtained from renal scintigraphy (GFR_RS) were compared with the reference GFR (GFR_Ref) acquired using the two plasma sample method. The correlation and agreement between GFR_MRR and GFR_Ref, GFR_RS and GFR_Ref, and single-kidney GFR_MRR (skGFR_MRR) and single-kidney GFR_RS (skGFR_RS) were assessed. The interrater reliability of DCE-MRR and the interrater reliability of renal scintigraphy (RS) were measured. RESULTS. Both GFR_MRR and GFR_RS correlated well with GFR_Ref. In patients with hydronephrosis, DCE-MRR and RS overestimated GFR by 12.8 ± 13.9 mL/min (mean ± SD) and 11.5 ± 12.3 mL/min, respectively. The skGFR_RS was higher than skGFR_MRR by 5.7 ± 3.8 mL/min in high-grade hydronephrotic kidneys (p = 0.004). Good interrater reliability was observed for skGFR_MRR (intraclass correlation coefficient [ICC] = 0.82-0.92) and skGFR_RS (ICC = 0.79-0.90) for both nonhydronephrotic kidneys and hydronephrotic kidneys. The overall mean SDs of repeated measurements from three investigators were 4.0 and 3.8 mL/min for skGFR_MRR and skGFR_RS, respectively. CONCLUSION. Both DCE-MRR and RS tend to overestimate GFR in patients with hydronephrosis. RS-derived skGFR is slightly higher than that of DCE-MRR in kidneys with high-grade hydronephrosis. DCE-MRR is comparable to RS and may serve as an alternative noninvasive method for GFR measurement.

Impact of Renal Artery Stent-Graft Placement on Renal Function in Chronic Aortic Dissection

PURPOSE

To evaluate the effect of renal stent-graft placement on kidney function and size alternation in chronic aortic dissection.

MATERIALS AND METHODS

Twenty-five consecutive patients with chronic aortic dissection after thoracic endovascular aortic repair who underwent renal stent-graft placement between January 2015 and December 2016 were retrospectively reviewed. Forty-three patients with chronic aortic dissection who received thoracic endovascular aortic repair in the same period were reviewed as a control group for kidney volume comparison.

RESULTS

Twenty-five stent-grafts were deployed over 25 renal arteries. Overall renal function was assessed by the slope of the regression line constructed from the plots of creatinine clearance versus time within 2 years after the procedure (-0.2810 vs -0.3146 mL/min^-1/mo^-1, P = .868), kidney volume at 12 months (129.4 ± 40.9 vs 137.0 ± 44.2 cm², P = .193) and effective renal plasma flow at 6 months (106.3 ± 46.9 vs 124.4 ± 55.5 mL/min, P = .050) and was not significantly deteriorated. Seven treated patients (87.5%) with a renal artery supplied by a false lumen had a decrease in kidney volume, as did 14 patients (56%) in the control group (P = .206). Three patients with a dissected renal artery (75%) in the stent-graft group had an increase in kidney volume compared with 1 patient (11.1%) in the control group (P = .052).

CONCLUSIONS

Occlusion of the re-entry tear by a stent-graft in the renal artery remains a safe strategy to promote false lumen thrombosis. The stent-graft poses a potential risk of reducing the kidney volume in kidneys supplied by the false lumen but may provide a positive effect in kidney volume with a concomitant dissected renal artery in chronic aortic dissection.

Measurement of single kidney glomerular filtration rate in dogs using dynamic contrast-enhanced magnetic resonance imaging and the Rutland-Patlak plot technique

Background

Nephropathies are among the most common diseases in dogs. Regular examination of the kidney function plays an important role for an adequate treatment scheme. The determination of the glomerular filtration rate (GFR) is seen as the gold standard in assessing the kidney status. Most of the tests have the disadvantage that only the complete glomerular filtration rate of both kidneys can be assessed and not the single kidney glomerular filtration rate. Imaging examination techniques like dynamic contrast-enhanced magnetic resonance imaging have the potential to evaluate the single kidney GFR. There are studies in human medicine describing the determination of the single kidney GFR using this technique. To our knowledge there are no such studies for dogs.

Results

An exponential fit was found to describe the functional interrelation between signal intensity and contrast medium concentrations. The changes of contrast medium concentrations during the contrast medium bolus propagation were calculated. The extreme values of contrast medium concentrations in the kidneys were reached at nearly the same time in every individual dog (1st maximum aorta 8.5 s, 1st maximum in both kidneys after about 14.5 s; maximum concentration values varied between 17 and 125 µmol/mL in the aorta and between 4 and 15 µmol/mL in the kidneys). The glomerular filtration rate was calculated from the concentration changes of the contrast medium using a modified Rutland-Patlak plot technique. The GFR was 12.7 ± 2.9 mL/min m² BS for the left kidney and 12.0 ± 2.2 mL/min/m² BS for the right kidney. The mean values of the coefficient of determination of the regression lines were averagely 0.91 ± 0.08.

Conclusions

The propagation of contrast medium bolus could be depicted well. The contrast medium proceeded in a similar manner for every individual dog. Additionally, the evaluation of the single kidney function of the individual dogs is possible with this method. A standardized examination procedure would be recommended in order to minimize influencing parameters.

Electronic supplementary material

The online version of this article (10.1186/s13028-018-0423-3) contains supplementary material, which is available to authorized users.

Renal Functional MRI and Its Application

Renal function varies according to the nature and stage of diseases. Renal functional magnetic resonance imaging (fMRI), a technique considered superior to the most common method used to estimate the glomerular filtration rate, allows for noninvasive, accurate measurements of renal structures and functions in both animals and humans. It has become increasingly prevalent in research and clinical applications. In recent years, renal fMRI has developed rapidly with progress in MRI hardware and emerging postprocessing algorithms. Function-related imaging markers can be acquired via renal fMRI, encompassing water molecular diffusion, perfusion, and oxygenation. This review focuses on the progression and challenges of the main renal fMRI methods, including dynamic contrast-enhanced MRI, blood oxygen level-dependent MRI, diffusion-weighted imaging, diffusion tensor imaging, arterial spin labeling, fat fraction imaging, and their recent clinical applications.

LEVEL OF EVIDENCE

5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:863-881.

Dynamic contrast-enhanced MRI measurement of renal function in healthy participants

Background High repeatability, accuracy, and precision for renal function measurements need to be achieved to establish renal dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) as a clinically useful diagnostic tool. Purpose To investigate the repeatability, accuracy, and precision of DCE-MRI measured renal perfusion and glomerular filtration rate (GFR) using iohexol-GFR as the reference method. Material and Methods Twenty healthy non-smoking volunteers underwent repeated DCE-MRI and an iohexol-GFR within a period of 10 days. Single-kidney (SK) MRI measurements of perfusion (blood flow, F_b) and filtration (GFR) were derived from parenchymal intensity time curves fitted to a two-compartment filtration model. The repeatability of the SK-MRI measurements was assessed using coefficient of variation (CV). Using iohexol-GFR as reference method, the accuracy of total MR-GFR was determined by mean difference (MD) and precision by limits of agreement (LoA). Results SK-F_b (MR1, 345 ± 84; MR2, 371 ± 103 mL/100 mL/min) and SK-GFR (MR1, 52 ± 14; MR2, 54 ± 10 mL/min/1.73 m²) measurements achieved a repeatability (CV) in the range of 15-22%. With reference to iohexol-GFR, MR-GFR was determined with a low mean difference but high LoA (MR1, MD 1.5 mL/min/1.73 m², LoA [-42, 45]; MR2, MD 6.1 mL/min/1.73 m², LoA [-26, 38]). Eighty percent and 90% of MR-GFR measurements were determined within ± 30% of the iohexol-GFR for MR1 and MR2, respectively. Conclusion Good repeatability of SK-MRI measurements and good agreement between MR-GFR and iohexol-GFR provide a high clinical potential of DCE-MRI for renal function assessment. A moderate precision in MR-derived estimates indicates that the method cannot yet be used in clinical routine.

Innovative Perspective: Gadolinium-Free Magnetic Resonance Imaging in Long-Term Follow-Up after Kidney Transplantation

Since the mid-1980s magnetic resonance imaging (MRI) has been investigated as a non- or minimally invasive tool to probe kidney allograft function. Despite this long-standing interest, MRI still plays a subordinate role in daily practice of transplantation nephrology. With the introduction of new functional MRI techniques, administration of exogenous gadolinium-based contrast agents has often become unnecessary and true non-invasive assessment of allograft function has become possible. This raises the question why application of MRI in the follow-up of kidney transplantation remains restricted, despite promising results. Current literature on kidney allograft MRI is mainly focused on assessment of (sub) acute kidney injury after transplantation. The aim of this review is to survey whether MRI can provide valuable diagnostic information beyond 1 year after kidney transplantation from a mechanistic point of view. The driving force behind chronic allograft nephropathy is believed to be chronic hypoxia. Based on this, techniques that visualize kidney perfusion and oxygenation, scarring, and parenchymal inflammation deserve special interest. We propose that functional MRI mechanistically provides tools for diagnostic work-up in long-term follow-up of kidney allografts.

7 T renal MRI: challenges and promises

The progression to 7 Tesla (7 T) magnetic resonance imaging (MRI) yields promises of substantial increase in signal-to-noise (SNR) ratio. This increase can be traded off to increase image spatial resolution or to decrease acquisition time. However, renal 7 T MRI remains challenging due to inhomogeneity of the radiofrequency field and due to specific absorption rate (SAR) constraints. A number of studies has been published in the field of renal 7 T imaging. While the focus initially was on anatomic imaging and renal MR angiography, later studies have explored renal functional imaging. Although anatomic imaging remains somewhat limited by inhomogeneous excitation and SAR constraints, functional imaging results are promising. The increased SNR at 7 T has been particularly advantageous for blood oxygen level-dependent and arterial spin labelling MRI, as well as sodium MR imaging, thanks to changes in field-strength-dependent magnetic properties. Here, we provide an overview of the currently available literature on renal 7 T MRI. In addition, we provide a brief overview of challenges and opportunities in renal 7 T MR imaging.